term 3

Question 1

What predisposes someone to developing meningitis?

Answer 1

sore throat for 3 days

Question 2

pt with meningitis has photophobie, and a severe headache, Which nursing interventions will be most helpful to provide relief from symptoms

Answer 2

darken the room, administer analgesics, minimal interruptions to pt.

Question 3

Which type of headache is most commonly associated with an aura?

Answer 3

migraine

Question 4

a pt. makes an appt with a dr for recurrent headaches. Which instructions will the nurse give the pt prior to them having the appt.?

Answer 4

keep a headache diary, recording symptoms, timing and headache triggers

Question 5

a pt who has had a generalized tonic clonic seizure is sound asleep 30 minutes after. Meals are about to be delivered. What action is most appropriate?

Answer 5

let the pt sleep during the postictal state and keep the meal warm

Question 6

a pt with history of seizures is experiencing an aura and is concerned about an impending seizure. What are the nursing interventions in the correct orderwhich pts should be closely monitored for symptoms of increased ICP?

Answer 6

pt with high fever and severe headache, the pt in PACU after a crainectomy, pt with brain tumor admitted for radiation therapy

Question 7

Which actions should the nurse take to help prevent IICP in a pt following a traumatic brain injury?

Answer 7

keep HOB elevated 30 degrees

Question 8

a pt with history of seizures is experiencing an aura and is concerned about an impending seizure. What are the nursing interventions in the correct order?

Answer 8

1) help the pt lie down in a safe place 2)protect the pt from injury during the seizure 3) turn the pt on their side to sleep 4) doocument the events of the seizure

Question 9

how much function can be expected in a pt with spinal cord injury at L2 level?

Answer 9

Paraplegic

may learn to walk with a brace

Question 10

Pt is admitted folliwing a T4 spinal injury, when taking vitals the nurse notices the BP is elevated, and pt is restless. What is an appropriate action for the nurse to take?

Answer 10

check for a full bladder, it could be a sign of autonomic dysreflexia

Question 11

the symptoms of Parkinson’s are caused by a depletion of which neurotransmitter?

Answer 11

Dopamine

Question 12

. Which nursing interventions are appropriate for the pt with a neurodegenerative d/o with difficulty swallowing?

Answer 12

show the pt how to tuck their chin down to chest when swallowing

Question 13

. A resident with Alzheimers is sitting in a corner crying saying that nobosy is paying attention. Which approach would best help the pt?

Answer 13

sit quietly by the pt and say “I’m here, youre not alone”

Question 14

A pt with trigeminal neuralgia asks the nurse why carbamazepine (Tegretol) has been ordered. Which response is best?

Answer 14

anticonvulsants help relieve nerve pain.

Question 15

a pt with amyotopic lateral sclerosis (ALS) expresses concern about not having enough breath to sing anymore. Which explanation by the nurse is best?

Answer 15

ALS causes weak muscles, if the repsiratory muscles are affected, breathing (and singing) could be compromised

Question 16

A pt who is newly diagnosed with ALS says to the nurse “I don’t want to be kept alive on machines” Which nursing action is the best response?

Answer 16

Ask the pt if they have an advanced directive in place, and give the pt info about preparing them

Question 17

When caring for a pt with Guillian-Barre syndrome, which nursing dx should take priority?

Answer 17

impaired gas exchange

Question 18

Which nursing int. are appropriate for the pt with Bell’s palsy?

Answer 18

administer eye drops, apply eye patch, apply warm compresses, provide facial massage

Question 19

Which meal is best for the pt with myasthenia gravis? (select all that apply question)

Answer 19

meat loaf, mashed potatoes and green beans (soft foods)

Question 20

How will the visiting nurse caring for a pt with myasthenia gravis and severe muscle weakness know if interventions have been effective?

Answer 20

the pt is able to perform ADLs with SAO2 remaining at 95%

Question 21

What functional classification of neurons carry impulses away from CNS to effectors?

Answer 21

motor (efferent) neurons

Question 22

Which structure in the CNS regulates body temp?

Answer 22

hypothalamus

Question 23

What are symptoms of IICP that should be reported immediately?

Answer 23

bradycardia, Increasing systolic BP with widening pulse pressure, irregular resps, commonly referred to as Cushings triad.

Question 24

Normal effects of aging on the CNS

Answer 24

reduced blood flow to the brain, impaired short term memory, sleep disturbance, decreased acetylcholine

Question 25

pt asks what to expect when she has an angiogram. Which response by the nurse is best?

Answer 25

a catheter will be placed in your femoral artery, and dye will be injected that will show up on xray

Question 26

. what should be encouraged when a pt returns from a CT scan using a contrast medium?

Answer 26

Drinking fluids (to help excrete the dye)

Question 27

Which of the following nursing interventions can prevent footdrop?

Answer 27

applying high top tennis shoes

Question 28

What are modifiable risk factors for stroke?

Answer 28

diabetes, high cholesterol, obesity

Question 29

what is the most important dx test that is completed imm. on the patients with symptoms of a stroke in the emergency dept.?

Answer 29

Head CT scan

Question 30

how soon after the symptoms onset must a person who has had a stroke receive thrombolytic tx?

Answer 30

3 hours

Question 31

pt is experiencing receptive aphasia. This means the pt has difficulty...

Answer 31

understanding language

Question 32

a nurse is caring for a pt recovering from an ischemic stroke. Upon entering the room the nurse notes the pt has only eaten half the meal. What should the nurse do?

Answer 32

turn the plate 180 degrees and observe the pts response

Question 33

The nurse is observing a new graduate performing an assessment on the Glascow coma scale. They should be assessing which 3 things?

Answer 33

eye opening verbal response motor response

Question 34

a pt arrives at the ER for a closed head injury. Which assessment finding should be reported immediately to the physician?

Answer 34

vomiting

Question 35

nurse is caring for a pt with a new dx of Parkinson's. What are 2 common symptoms of a pt with parkinsons (select all that apply ?)

Answer 35

shuffling gait, dysphagia

Question 36

Which assessment findings would indicate compromized neurovascular function (Select all that apply ?)

Answer 36

capillary refill time 6 seconds, numbness and tingling, blue discoloration to the skin

Question 37

.a nurse is caring for a pt who has an injury to the left motor area of the cerebrum. Where would the nurse expect to see paralysis?

Answer 37

the right side of the body (crossing nerve tracts in the brain)

Question 38

a pt has undergone a crainectomy for removal of a meningioma. What question would be appropriate in assessing a possible complication of the surgery

Answer 38

have you noticed any salty or sweet tasting drainage coming from the incision site?"

Question 39

When planning care for a pt with ALS, a priority nursing intervention would inclute

Answer 39

maintain clear airway

Question 40

A pt with a head injury has been ordered mannitol via IV. The pt is most likely to receive mannitol for what?

Answer 40

IICP

Question 41

a nurse is caring for a pt dx with meningitis. the pt is extremely photophobic and her mother sits at her bedside crying. What should be included in this pts plan of care?

Answer 41

maintaining a calm relaxed environment

Question 42

Which of the following concerns is a priority in a pt with an open head injury? (once bleeding has been controlled)

Answer 42

infection

Question 43

pt has a seizure accompanied with incontinence. The pt sleeps for several hours afterward. What kind of seizure has the pt most likely experienced?

Answer 43

tonic-clonic

Question 44

. a pt asks the nurse why she must lie flat after her lumber puncture. the nurse correctly answers the pt by saying...

Answer 44

you might get a bad headache if you sit up now"

Question 45

a pt is being observice for ICP which classification of drugs besides corticosteroid and anticonvulsants, would the nurse expect the physician to order?

Answer 45

osmotic diuretics

Question 46

When teaching a pt who is experiencing migraines, which of the following indicates the pt teaching has been successful?

Answer 46

the pt can identify triggers of the migraines

Question 47

A pt is unable to respond appropriately and clearly. He is is oriented to time but unable to follow commands. What best describes their LOC?

Answer 47

confused

Question 48

. What is the most common cause of autonomic dysreflexia? what are some other common causes?

Answer 48

full bladder; fecal impaction, kinked foley

Question 49

when a . pt admitted with a GCS of 13 and 15. the nurse knows this indicates...

Answer 49

optimal cerebral functioning

Question 50

what are late signs of ICP/

Answer 50

elevated temp, elevated bp, decreased pulse, decreased respirations

Question 51

. a pt with Gullian-Barre syndrome may experience what ?

Answer 51

possible ascending paralysis

Question 52

Trigeminal neuralgia affects which nerve?

Answer 52

5th cranial nerve (sensory) trigeminal nerve

Question 53

.Bells palsy affects which nerve?

Answer 53

7th cranial nerve, (motor) facial nerve

Question 54

ALS (Lou Gehrig's Disease)

Answer 54

progressive motor neuron disorder, muscle weakness

Question 55

parkinsons disease is caused by a depletion of ____ and an increase of _______

Answer 55

dopamine, aceytlcholine

Question 56

Main nursing goal for parkinsons disease

Answer 56

maintain independence as long as possible

Question 57

alzheimers disease key nursing intervention

Answer 57

patient safety

Question 58

Multiple sclerosis

Answer 58

Destroys patches of myelin in brain and spinal cord, disrupt neuronal signals in CNS results in muscle weakness, with exascerbations and remissions

Question 59

pt teaching pts with MS

Answer 59

avoid extremes in temps. (extreme heat or cold), activities with frequent rest periods

Question 60

Epideral hematoma

Answer 60

arterial; rapid, may lead to death (blood between the dura mater and skull) AKA "talk & drop injury)

Question 61

Subdoral Hematoma

Answer 61

Slow venous bleeding between dura mater and arachnoid space. symptoms may take up to 24 hours after injury. pressure build up in brain.

Question 62

. homonymous hemianopsia

Answer 62

lost visual field

Question 63

Nursing interventions for cva

Answer 63

``` Airway!! Neuro checks Check for ICP I and o Bowel and bladder training ROM Communication system Safety measures ```

Question 64

. CVA s/s

Answer 64

headache, confusion, vertigo, transient hemiparesis, temporary vision changes, syncope

Question 65

Signs of IICP

Answer 65

changes in LOC, headache, pulillary changes, papilledema, decreased motor/sensory function

Question 66

. Autonomic dysreflexia

Answer 66

spinal cord injury at t-6 or higher; triggered by sustained stimuli at t6 or below

Question 67

Autonomic dysreflexia causes

Answer 67

full bladder or UTI, fecal impaction, pressure sores, restrictive clothing

Question 68

.s/s of autonomic dysreflexia

Answer 68

inc. bp, flushed face, headache, JVD, decreased heart rate, diaphoresis

Question 69

. Parkinson's Disease s/s

Answer 69

tremors, bradykinesia, muscle rigidity

Question 70

. Nursing interventions: pts with parkinson's

Answer 70

provide assistance with ROM exercises, encourage pt to participate in ADL's, keep env. free from clutter, promote independence as long as possible

Question 71

Bell's Palsy nursing interventions

Answer 71

assess pain level and response to interventions, teach pt to chew on unaffected side, may use eye patch to prevent injury to the eye

Question 72

agnosis/agnosia

Answer 72

inability to recognize familiar objects

Question 73

. nursing care for pt with MS

Answer 73

monitor respiratory rate, breath sounds, O2 sat, Elevate HOB, encourage pt to perform self care as much as possible, active/passive ROM

Question 74

Things that may exascerbate Gullian Barre syndrome

Answer 74

recent immunizations/ recent viral infections

Question 75

Partial Seizure (simple partial seizure)

Answer 75

repetitive purposeless behaviors ; pt appears to be in dream like state, no loss of consciuosness

Question 76

Who are Absence seizure (Petit-mal) most often seen in ?

Answer 76

children and is manifested by staring that lasts several seconds

Question 77

Tonic clonic seizure (grand-mal)

Answer 77

follows a typical progression: aura, Loss of consciousness, tonic phase, clonic phase, postoctical period

Question 78

What is the clonic phase (grand mal seizure) signaled by ?

Answer 78

-contraction & relaxation of all muscles in a jerky rhythmic manner, -pt is often incontinent

Question 79

What is the Postictal period?

Answer 79

period right after the seizure. usually involves fatigue, mental status changes, head ache, etc

Question 80

How long does the tonic phase (grand mal seizures) last ?

Answer 80

30-60 seconds of rigidity, pupils fixed, dilated, hands jaw clenched, may be temporarily apneic

Question 81

what can leakage from the nose or ear of spinal fluid indicate ?

Answer 81

icp & internal damage

Question 82

what is important for patients with alzheimers ?

Answer 82

nutrition (finger foods)sandwich,milkshake

Question 83

what clients are at risk for ICP ?

Answer 83

patients that had brain surgey brain tumor high temp and headache )

Question 84

what are signs of meningitis and esiphilitis ?

Answer 84

high temperature and headache

Question 85

what is bells palsy & and what can be givin for he dry eyes ?

Answer 85

like a stroke half of the face is droop artificial tears of eye drop

Question 86

when a patient has meningitis ,what examination has to be done ?

Answer 86

a spinal tap

Question 87

what triggers trigeminal neuralgia ?

Answer 87

extremes of hot and cold

Question 88

what kind of water does a patient with trigemnila neuralgia has to use on face ?

Answer 88

room temp luke warm room temp mouth wash tootheths for sensitivity

Question 89

what kind of food do trigeminal neuralgia patient eat ?

Answer 89

liquid diet or soft diet

Question 90

What is status epilepticus ?

Answer 90

30 miniatures of repititive seizure activity without a return of conciousness